ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?
Correct Answer: A
Rationale: The correct answer is A: Administer high-ceiling (loop) diuretics. In fluid overload, loop diuretics help the body eliminate excess fluid rapidly, which is a priority intervention. Assessing lung sounds (B) is important but not as urgent as addressing the fluid overload. Placing a pressure-relieving overlay (C) is not directly related to managing fluid overload. Weighing the client daily (D) is important for monitoring fluid status but does not address the immediate need for fluid removal.
Question 2 of 5
A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy?
Correct Answer: D
Rationale: The correct answer is D: Internal and superficial bleeding. Thrombolytic therapy works by breaking down blood clots, which can lead to bleeding as a side effect. This is the most common undesirable effect because it is directly related to the mechanism of action of thrombolytic agents. Dysrhythmias (choice A), although possible, are less common and not directly related to the drug's action. Nausea and vomiting (choice B) are general side effects that are not specific to thrombolytic therapy. Anaphylactic reactions (choice C) are rare but serious adverse effects that can occur with any medication, not just thrombolytics.
Question 3 of 5
What finding should the nurse expect during the assessment of a young adult with infective endocarditis (IE)?
Correct Answer: B
Rationale: The correct answer is B: A new regurgitant murmur. In infective endocarditis, vegetation on heart valves can cause valve dysfunction, leading to new regurgitant murmurs. This is a classic finding in IE assessment. Substernal chest pressure (A) is more common in conditions like angina or myocardial infarction. Pruritic rash on the chest (C) is not typically associated with IE. Involuntary muscle movement (D) is not a common finding in IE and is more suggestive of neurological conditions.
Question 4 of 5
Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)?
Correct Answer: B
Rationale: The correct answer is B: Ask about chest pain. This is because assessing the presence or absence of chest pain is a critical indicator of the effectiveness of IV nitroglycerin in managing myocardial infarction. Chest pain is a cardinal symptom of MI, and the relief or reduction of chest pain indicates that the nitroglycerin is working to improve blood flow to the heart muscle. Monitoring heart rate, checking blood pressure, and observing for dysrhythmias are important assessments in managing MI, but they do not directly reflect the effectiveness of nitroglycerin therapy.
Question 5 of 5
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take?
Correct Answer: D
Rationale: The correct answer is D because administering pain medication will help alleviate the client's discomfort, enabling them to take deep breaths essential for lung expansion following chest tube placement. Deep breathing prevents complications like atelectasis. Option A is incorrect as ambulation may be painful. Option B does not address the client's pain issue. Option C is wrong because shallow breaths can lead to lung complications.